Payment Verification Form

Please return the following form along with the identification documents listed below:

1. Photo of ID (back and front in color);

2. Photo of the credit card used (back and front in color). Company requires only first 6 and last 4 digits, expiry
date and card holder's name on the front to verify it in the system with the card holderʼs signature on the back;
3. Clear photo of the player holding his/her ID (in color);
4. Card verification form for each card used for deposits;
5. Utility bill (or any other official document, containing playerʼs current physical address and full name on it),
issued within 3 (three) months.

Documents to be submitted via email: verification@twoupcasino.com

Full Name: Address:

Login: City:

Date of Birth: State / Prov:

Phone: Zip / Post Code:

Email: Country:

Bank Name:

Bank Address:

Acct. Holder’s Name:

Account Number:

ABA Routing Nº for international wire deposit:

SWIFT/ BIC Code:

BSB Number: (AU/NZ):

Bank code (Canada):

Transit ID (Canada):

IBAN Number (Europe):

Alternative Withdrawal Methods:

* Please be informed that a copy of the voided check is needed for bank details validation (optional).

All withdrawal requests must first be reviewed and approved by the casino finance department before being sent for payment.

We record and store all interactions between the customers and the company. This record shall be used in case a dispute arises between the
customer and Two-Up Casino as a guarantee of its successful resolution. Please note that Two-Up Casino is not liable for the accuracy of the
beneficiary details submitted in the form. By placing the signature below, you therefore acknowledge the credibility of the information provided and
agree to act in accordance with the Terms and Conditions.

Signature Date